| INSURANCE VERIFICATION INFORMATION |
COVERAGE DETERMINATION:
YES
NO, UNLESS PROVED MEDICALLY NECESSARY
NO, DIRECT EXCLUSION
CRITERIA TO MEET MEDICAL NECESITY:
BMI 35-39.9 W / HEALTH CONDITIONS / 40 OR GREATER MUST BE 40 OR GRATER
MORBID OBESITY PROVED FOR: 2 YRS 3 YRS 5 YRS
3 MONTH PREPARATORY PROGRAM: COMPLETED BY SURGEON CANNOT BE SURGEON
6 MONTH PHYSICIAN DIRECTED W/REDUCED CALORIE DIET, EXERCISE, BEHAVIOR MODIFICATION:
6 MONTH PROGRAM CAN BE DIRECTED BY: SURGEON CANNOT BE SURGEON
SURGEON/ FACILITY MUST BE A COE SURGEON/ FACILITY MUST BE INSURANCE CERTIFIED
BENEFIT PLAN:
DEDUCTIBLE AMOUNT IN_NETWORK $ OUT OF NETWORK $
HAS DEDUCTIBLE BEEN MET? YES NO
SPECIALIST CO-PAY AMOUNT $
DOES THE EMPLOYER REQUIRE A PREFERRED PROVIDER? YES NO
ARE WE ON THE PANEL? YES NO
ARE WE IN_NETWORK WITH THE PANEL? YES NO
PRECERTIFICATION PHONE#: PRECERT. FAX#:
NAME OF PERSON(S) SPOKEN WITH:
REFERENCE NUMBER TO THE CALL#
NOTES
NAME OF PERSON DOING VERIFICATION BENEFITS:
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